Reference Release Form
Adams Stirling PLC


Applicant name:                                                                                                       
Former employer:                                                                                                       
Social Security No:                                       Dates employed:                                       

The above applicant is being considered for employment with                                              and has listed your organization as a former employer. We would appreciate your completion of this form at your earliest convenience. The Information you provide will be treated in confidence. Please return this form to us in the enclosed, self-addressed, stamped envelope. Thank you for your assistance.

Applicant's Authorization

I authorize my former employer, and its agents and employees, to provide information about my work performance, wage history, attendance, personal history, disciplinary information and reason for separation of employment. The information is for the purpose of determining my acceptability for employment. I also hereby release the above named former employer, and its agents and employees, from all liability for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and negligence, which may arise or result from any reference information provided pursuant to this authorization.

Applicant's signature:                                                                  Date:                        

Record of Employment

Position held:                                                Dates employed:                                     

Summary of applicant's duties:                                                                                     

Reason for leaving:                                                                                                    
Salary at termination:                                             Eligible for rehire?   ____ Yes  ____ No
Please rate the following: Excellent Good Average Fair Poor
Job Knowledge          
Overall Performance          


Signature:                                                   Title:                             Date:                 

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Adams Stirling PLC